Health Insurers How Germany’s Health System Makes People Sick

Since 2009, German statutory health insurers with large numbers of chronically sick patients have been receiving extra money. Experts warn that the revised funding arrangements are encouraging over-diagnosis and deterring disease prevention.
Some suspect the funding system is increasingly deterring health insurers from launching special programs for the prevention of avoidable diseases.

Germany’s AOK statutory health insurance organization, which covers more than 24.4 million people or almost a third of the population, got a helping hand in 2009. The government that year expanded its funding by reforming an equalization system that compensates insurers with a disproportionately high number of elderly and chronically sick people on its books.

A new health fund set up in 2009 to collect insurance contributions and divide them up more fairly among the more than 130 statutory health insurers had the desired effect: it helped the AOK group.

But it had some major unfortunate side effects for Germany’s health insurance system in general. Health experts warned all along that the reorganization could remove incentives to prevent avoidable ailments such as obesity, heart disease and diabetes.

Our health care system is more and more mutating into an economic market. Sigrid König,, BKK Bavaria

Under the system in place since 2009, around half the health fund’s resources are distributed among the insurers according to the share of their patients suffering from 80 mostly chronic diseases.

The organization of 87 company-linked health insurance funds, known as Betriebskrankenkassen, or BKK, which together cover some 10 million people, recently provided figures that appear to confirm the fears of those experts.

The data show that between 2013 and 2014, the number of people diagnosed with obesity defined as a Body Mass Index, or BMI, of more than 35 jumped by 50 percent.

Manuela Osterloh, the spokeswoman of the Bavaria regional BKK organisation, said she was certain that doctors were reporting BMI levels more frequently to secure funding under the health fund’s equalization system.

In addition, the fund pays out more money according to complications associated with chronic diseases, reflected in hospital stays and drug prescriptions. If patients with diabetes or other chronic diseases suffer complications, the fund pays out more money.

Here, too, the BKK group detected an increase. Since 2010, the number of insured people with four or more diseases eligible for extra funding has increased by 13 percent. And between 2009 and 2014, the number of diagnosed cases eligible for additional funding rose by almost a fifth.

“Our health care system is more and more mutating into an economic market,” Sigrid König, the head of the BKK’s Bavarian association, told Handelsblatt. “The currency in this system is diagnosed diseases.”

This was why the incidence of such diseases had been increasing more strongly than could be explained by the aging of the population, she said.

Ms. König suspects that the funding system is increasingly deterring health insurers from launching special programs for the prevention of avoidable diseases like diabetes and heart disease — because such programs aren’t eligible for additional funding.

The AOK group rejected that interpretation. “It is pretty absurd to now attribute the over-, under- and misallocation of resources in the health system, which has been known about for years, to the financial equalization system,” a spokesman for the group said.

The true problem wasn’t the diagnosis of diseases but the number of questionable operations, superfluous diagnostic procedures and unnecessary regulations on drugs, the spokesman said.

“These structural deficits produce additional costs that go far beyond what can be explained by demographic change, and can only be removed through structural reforms,” he added.

The AOK and BKK agree on one point, however, according to the AOK spokesman: the need for uniform, binding standards for diagnosing diseases to make the system more transparent and to avoid distorting competition among the health insurers.

In 1883, Germany became the first country to introduce a national health insurance system. It covered industrial workers and tradesmen. The insurance contributions, paid jointly by workers and their employers, were the same regardless of age, gender or one’s health.

Today more than 85 percent of Germans, or 70 million, are covered by 132 statutory health insurance companies. A further 9 million are privately insured and the remaining 3 million have special insurance programs that cover organizations such as the army. A total of 99.8 percent of people in Germany have health insurance.


Peter Thelen writes about social security systems, the job market and labor topics. To contact the author: [email protected]